=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639531148
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | US MENS MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/23/2016
-----------------------------------------------------
Last Update Date | 09/29/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1334 HERITAGE PKWY
-----------------------------------------------------
City | WENTZVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63385-3570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 636-288-5225
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1334 HERITAGE PKWY
-----------------------------------------------------
City | WENTZVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63385-3570
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER/OWNER
-----------------------------------------------------
Name | DEREK J LAMBERT
-----------------------------------------------------
Credential | NP-C
-----------------------------------------------------
Telephone | 636-288-5225
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 2015008642
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------